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Abstract: The patient was admitted to the hospital because of recurrent dizziness and weakness for more than 10 years. Since 2009, elevated blood pressure up to 165/120 mmHg was found, which was treated with medication with poor blood pressure control, normal blood potassium, elevated blood aldosterone, and thickened left adrenal gland on enhanced CT of the adrenal glands. The saline suppression test confirmed secondary hypertension and primary aldosteronism. Further adrenal venous blood sampling (AVS) was performed, suggesting the presence of dominant secretion in the left adrenal gland, and the symptoms improved significantly after surgical treatment.
Basic information】Female, 45 years old
Disease Type】Secondary hypertension, primary aldosteronism
Hospital】Zhejiang Provincial People’s Hospital
Consultation time】August 2019
Treatment plan】Laparoscopic left adrenalectomy
Treatment Period】Hospitalization for more than 2 months, regular outpatient review
Effectiveness】Blood pressure decreased significantly, clinical symptoms and biochemical indexes improved
I. Initial consultation
Patient Ms. Li was admitted to the hospital because of recurrent dizziness and weakness for more than 10 years, and her blood pressure was found to be elevated up to 165/120 mmHg since 2009. Outpatient testing revealed significantly elevated aldosterone levels and aldosterone-to-renin ratio (ARR), with no significant abnormalities seen on adrenal ultrasound. Because of the abnormally elevated ARR, the possibility of primary aldosteronism (PA) needs to be considered clinically. Although no adrenal hyperplasia or nodule-like changes were seen on the adrenal ultrasound, further saline suppression tests are necessary to confirm the diagnosis of PA, and an enhanced CT scan of the adrenal glands for the presence of adrenal hyperplasia or nodules is recommended. If the diagnosis of PA is confirmed and there is a desire for surgery, further adrenal venous blood collection is recommended for local diagnosis, which the patient accepts and expresses positive cooperation.
Ultrasound examination of the adrenal glands
II. Treatment history
After admission, a saline suppression test was performed on the patient. Before the test, aldosterone was 708 pg/ml and renin activity was 0.082 ng/ml/h. After the test, aldosterone was 508.6 pg/ml and renin activity was 0.103 ng/ml/h. Blood potassium was 3.67 mmol/L because aldosterone was greater than 100 pg/ml after the saline suppression test. On October 7, the patient underwent laparoscopic left adrenalectomy under general anesthesia, and the operation went smoothly. The operation went smoothly and the patient returned to the ward safely after the operation.
Results of adrenal venous blood collection
III. Treatment effect
After left adrenalectomy, the patient’s blood pressure and aldosterone levels decreased compared with those before, and he was discharged 1 week after surgery. aldosterone 228.2 pg/ml, renin activity 4.979 ng/ml/h, blood potassium 3.95 mmol/L were rechecked on November 19, 2019, and aldosterone 145 pg/ml, renin activity 0.693 ng/ml/h on March 30, 2021. /The postoperative renin activity increased significantly, suggesting that the previously suppressed renin activity was restored, and the blood potassium also increased compared with the previous one, although the change was not significant.
IV. Notes
We are glad that after treatment the patient’s blood pressure dropped significantly and the clinical symptoms and biochemical indexes improved. We suggest that the patient should pay attention to maintaining a good lifestyle after discharge, including a light diet, regular exercise and combining work and rest. Also adhere to the antihypertensive drugs, close monitoring of blood pressure, if the blood pressure continues to be lower than 120/70mmHg after drug reduction, you can come to the hospital to review follow medical advice in a period of time to discontinue drug observation. If your blood pressure exceeds 135/85mmHg, you should come to the hospital for review and treatment with amlodipine. If your blood pressure remains high or if you experience significant discomfort, you should seek medical attention.
V. Personal insight
Due to economic conditions, medical level and ideology, most patients with PA worldwide are not diagnosed in time and are treated as primary hypertension. Although the blood pressure of these patients is well controlled, the toxic effects of aldosterone on cardiovascular and renal organs are not removed, and complications such as myocardial hypertrophy, arrhythmia and chronic kidney disease are not really reduced. In areas where it is available, it is necessary to screen and confirm the diagnosis of PA in patients with primary hypertension, hypertension combined with hypokalemia, refractory hypertension, and adrenal hyperplasia or nodules found in the adrenal glands for precise targeting and optimal treatment plan.